IMPORTANT NOTICES. Office visits and/or procedures at PAR/Network Providers do not require PA. Referrals to PAR/Network Specialists do not require PA.

Transcription

1 , PA Code Matrix IMPORTANT NOTICES This document is updated quarterly. Please check this document prior to PA submission as codes may be removed or added. All codes listed require PA unless there is a Plan-specific exception*. Office visits and/or procedures at PAR/Network Providers do not require PA. Referrals to PAR/Network Specialists do not require PA. Some services listed may not be covered by CMS or your local State Medicaid or Marketplace agency; please refer to your regulatory agency for specific noncovered codes. Authorization is not a guarantee of payment for services. Payment is made in accordance with a determination of the member s eligibility, benefit limitation/exclusions, and evidence of medical necessity during the claim review. To search this document, use [Ctrl + F] keys; enter Service or Code in search navigation pane at left; press Enter. *Refer to Molina Plan Exceptions section Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 1

2 , PA Code Matrix Table of Contents Document Change Tracking... 3 Behavioral Health, Mental Health, Alcohol & Chemical Dependency Services... 9 Cosmetic, Plastic & Reconstructive Procedures (in ANY setting)... 9 Durable Medical Equipment (DME) Experimental/Investigational Genetic Counseling & Testing Habilitative Therapy Home Health Care & Home Infusion Hyperbaric Therapy Imaging Advanced & Specialty In-Patient Admissions Long Term Services & Support Neuropsychological & Psychological Testing Non-Par Offices/Providers/Facilities Office Based Procedures Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures Pain Management Procedures Pregnancy and Delivery Prosthetics & Orthotics Radiation Therapy & Radio Surgery Sleep Studies Speech Therapy Specialty Pharmacy Drugs (Injectable) Transplant Services (Including Solid Organ and Bone Marrow) Transportation Services (Non-Emergent) Unlisted/Miscellaneous Codes Medicare Exceptions Molina Plan Code Exceptions Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 2

3 Document Change Tracking Received Date Effective Date, PA Code Matrix Specialty/Service Change/Update Description Exceptions/Notes 05/01/14 05/15/14 OP Hospital/ASC procedures Removed/No PA Required: /15/14 07/17/14 OP Hospital/ASC procedures Removed/No PA Required: 97002*, 92521, 92522, *MHFL: PA required 92523, /28/14 06/27/14 Radiation Therapy & Removed/No PA Required: Radiosurgery 05/28/14 06/27/14 OP Hospital/ASC procedures Removed/No PA Required: MPR 06/10/14 10/28/14 Genetic Counseling & Testing Removed/No PA Required: 81504, /10/14 10/23/14 OP Hospital/ASC procedures Removed/No PA Required: /26/14 10/28/14 Podiatry Removed/No PA Required all related codes. No auth needed when done in PAR office. 08/01/14 10/28/14 Physical Therapy custom Added/PA Required all related codes content 08/01/14 10/28/14 Pain Management Therapy Added/PA Required all related codes custom content 08/01/14 10/28/14 Behavioral Health Therapy Added/PA Required all related codes custom content 10/07/14 11/26/14 Genetic Counseling & Testing Removed/No PA Required: 81506, 81503, /15/14 12/05/14 Non Emergent Air/Ground Added/PA Required: A0426, A0428, A0430, A0431, Transportation services S9960, S /15/14 12/17/14 Specialty Pharmacy drugs Removed/No PA Required: J /15/14 12/17/14 Behavioral Health Added/PA Required: Removed/No PA Required: H2014* *MHNM: PA Required 12/15/14 12/17/14 OP Hospital/ASC procedures Removed/No PA Required: MHTX: Non covered code 11/09/14 12/17/14 OP Hospital/ASC procedures Removed/No PA Required: 90832, 90833, 90834, 90836, 90837, 90838, 90845, 90846, 90847, 90848, 90849, 90853, 90899, 95950, 95951, will remain under Unlisted/T codes will remain under neuropsychological testing. 11/14/14 12/17/14 Prosthetics & Orthotics Added/PA Required: L /14/14 01/01/15 Neuropsychological & Removed/No PA Required: 96110, Psychological testing 11/18/14 12/17/14 Specialty Pharmacy & T codes Removed/No PA Required: J7301, J7302, 59899, /14/14 12/18/14 BH, mental health, alcohol & PA Required: S0201 MTX: Non covered code chemical dependency 12/14/14 12/18/14 BH, mental health, alcohol & Removed/No PA Required: H0016, H0031 chemical dependency 12/22/14 12/22/14 Physical Therapy PA Required: 0420, 0421, 0422, 0423, 0424, 0429 MHTX: Non covered codes 12/22/14 12/22/14 Occupational Therapy PA Required: 0430, 0431, 0432, 0433, 0434, /22/14 12/22/14 Speech Therapy PA Required: 0440, 0441, 0442, 0443, 0444, /31/14 01/01/15 OP Hospital/ASC procedures Removed/No PA Required: 96150, 96151, 96152, 96153, 96154, /31/14 01/01/15 OP Hospital/ASC procedures Removed/No PA Required: 90865, 90875, 90876, 90882, 90901, /31/14 01/01/15 BH, mental health, alcohol & Removed/No PA Required: H2017, Q3014 chemical dependency 01/12/15 01/12/15 Wound therapy, including wound Vacs & Hyperbaric wound therapy Removed/No PA Required: G0456, G /14/15 01/14/15 Radiation Therapy and Radio Surgery Removed/No PA Required: Added/PA Required: 77385, 77306, 77307, 77316, 77317, 77318, 77402, 77407, 77412, Removed Termed Codes: 0073T, 77305, 77310, 77315, 77326, 77327, 77328, 77403, 77404, 77406, 77408, 77409, 77411, 77413, 77414, 77416, /22/15 01/22/15 Pain Management Procedures Added/PA Required: /22/15 01/22/15 OP Hospital/ASC procedures Added/PA Required: 33418, /26/15 01/26/15 OP Hospital/ASC procedures Removed/No PA Required: 98925, 98926, 98927, 98928, /06/15 02/06/15 OP Hospital/ASC procedures Added/PA Required: (based on MCG-218) Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 3

4 , PA Code Matrix Received Effective Date Date Specialty/Service Change/Update Description Exceptions/Notes 02/06/15 02/06/15 Experimental/Investigational & Removed/No PA Required: 0232T Unlisted Misc. codes 02/06/15 02/06/15 Wound therapy, including Removed/No PA Required: G0460 wound Vacs & Hyperbaric wound therapy 02/06/15 02/06/15 Radiation Therapy and Radio Added/PA Required: G0339; G0340 (based on MCG- Surgery 224) 02/23/15 02/23/15 Specialty Pharmacy Drugs Added/PA Required (based on MCGs): (Injectable) J1725, J0598, J9010, J9035, J2796, J7336, J2212, S0073, C /03/15 03/03/15 OP Hospital/ASC procedures Removed/No PA Required: /03/15 03/03/15 DME Added/PA Required: C /03/15 03/03/15 Experimental/Investigational Added/PA Required: /03/15 03/03/15 Genetic Counseling & Testing Added/PA Required: 81246, 81288, 81313, 81410, 81411, 81415, 81416, 81417, 81425, 81426, 81427, 81430, 81431, 81435, 81436, 81440, 81445, 81450, 81455, 81460, 81465, 81470, 81471, 81519, 83006, 88369, 88373, 88374, /03/15 03/03/15 Wound therapy, including Added/PA Required: G0277, 97607, wound Vacs & Hyperbaric wound therapy 03/03/15 03/03/15 OP Hospital/ASC procedures Added/PA Required: 52441, 52442, 66179, 66184, G /03/15 03/03/15 Pain Management procedures Added/PA Required: 64486, 64487, 64488, /03/15 03/03/15 Specialty Pharmacy Drugs Added/PA Required: J0572, J0573, J0574, J0575, J0888, J1322, J7181, J7182, J7200, J7201, J7327, J7336, J9267, J9301, C9027, C9136, C9442, C9443, C9444, C /03/15 03/03/15 Prosthetics/Orthotics Added/PA Required: L6026, L /03/15 03/03/15 Radiation Therapy Added/PA Required: G6015, G6016, G /03/15 03/03/15 Unlisted/Misc./T Codes Added/PA Required: G /03/15 03/31/15 Multi-Specialties Removed Termed Codes: 00452, 0059T, 00622, 00634, 0092T, 0181T, 0197T, 0199T, 0226T, 0227T, 0239T, 0245T, 0246T, 0247T, 0248T, 0319T, 0320T, 0321T, 0322T, 0323T, 0324T, 0325T, 0326T, 0327T, 0328T, 0334T, 0343T, 0344T 22520, 22521, 22522, 22523, 22524, 22525, 33332, 33472, 33960, 33961, 36469, 36822, 43350, 61542, 61609, C9022, C9133, C9134, C9135, J0151, J3140, J3150, L6025, L7260, L7261, Q9970, Q9973, Q9974, S0144, S /06/15 03/06/15 OP Hospital/ASC procedures Removed/No PA Required: 55970, Medicare members only 03/11/15 01/01/15 OP Hospital/ASC procedures Removed/No PA Required: Retro to 01/01/15. 03/13/15 03/13/15 Neuropsychological & Added/PA Required: 95950, 95953, 95954, 95955, Psychological testing 95957, 95958, 95961, /13/15 03/13/15 BH, mental health, alcohol & Removed/No PA Required: H0020 chemical dependency 03/23/15 01/01/15 OP Hospital/ASC procedures Removed/No PA Required: 95990, 96409, 96417,. Retro to 01/01/ , 96401, 96411, 96420, 96450, 96402, 96413, 96422, 96542, 96405, 96415, 96423, 96549, 96406, 96416, /08/15 04/01/15 Specialty Pharmacy Drugs Added/PA Required: C9445, C9448, C9449, C9450,. Retro to 04/01/15 C9451, C9452, Q9975, J /01/15 07/01/15 OP Hospital/ASC procedures Removed/No PA Required: 36821, 96365, 96366, 96367, /01/15 07/01/15 All Changed name of this document from Codification Document to Services & Codes Requiring PA 05/20/15 07/01/15 Medicare Non Covered Codes & Removed non covered codes from document. Plan Non Covered Codes 06/18/15 07/01/15 Newborn screenings No PA required for NM: 82016, MHNM Only 06/18/15 07/01/15 Dopplers, Sedation, Dietitians, EMG/NCS No PA required for NM: 93922, 93923, 93924, 93925, 93926, 93930, 93931, 93965, 93970, 93971, 93975, 93976, 93978, 93979, 93980, 93981, 93990, 93880, MHNM Only Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 4

5 , PA Code Matrix Received Date Effective Date 07/01/15 07/10/15 OP Hospital/ASC procedures, T Codes, Experimental/ Investigational Specialty/Service Change/Update Description Exceptions/Notes 93882, 99143, 99144, 99145, 99148, 99149, 99150, 97802, 97803, 97804, 95861, 95863, 95864, 95865, 95866, 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95885, 95886, 95887, Removed/No PA Required: 33361, 33362, 33363, 33364, 33365, 33418, 33419, 0345t, G /17/15 07/01/15 Specialty Pharmacy Drugs Removed Termed Code: C9448 Added/PA Required: Q5101, C9453, C9454, C9455, Q9977, Q9978. Retro to 07/01/15. Retro to 07/01/15 07/17/15 07/01/15 Experimental/Investigational Added/PA Required: 0392T, 0393T. Retro to 07/01/15 07/17/15 07/01/15 Genetic Counseling & Testing Added/PA Required: 0010M. Retro to 07/01/15 07/15/15 07/01/15 BH, mental health, alcohol & chemical dependency Added/PA Required when submitted with Diagnosis of Autism: H0031, H0032*, H2012, H2014, H2017, H2019, T1023, T1025, T1026, T1027, T1028, T2013, T2040, S5150, , , , , , , , /22/15 08/01/15 Dialysis Removed/No PA Required: 90935, 90953, 90959, 90965, 90997, 90937, 90954, 90960, 90966, G0365, 90945, 90955, 90961, 90967, J0882, 90947, 90956, 90962, 90968, J0886, 90951, 90957, 90963, 90969, Q4081, 90952, 90958, 90964, /22/15 08/01/15 Hospice Removed/No PA Required: S0271, T2044, T2042, T2045, T2043, T /22/15 08/01/15 Dental Anesthesia Removed/No PA Required: D9219, /22/15 08/01/15 Durable Medical Equipment (DME) 07/22/15 08/01/15 Radiation Therapy & Radio Surgery Removed/No PA Required: A4639, A8000, A8001, A8002, A8003, A8004, E0184, E0186, E0193, E0196, E0197, E0198, E0217, E0225, E0239, E0445, E0450, E0470, E0471, E0472, E0480, E0482, E0565, E0601, E0610, E0615, E0617, E0618, E0619, E0620, E0627, E0628, E0629, E0636, E0640, E0650, E0651, E0652, E0656, E0657, E0667, E0668, E0670, E0671, E0672, E0673, E0675, E0731, E0740, E0947, E0948, E2100, E2120, K0455, K0609, K0730, Q0480, Q0481, Q0482, Q0483, Q0484, Q0485, Q0486, Q0487, Q0489, Q0490, Q0491, Q0493, Q0495, Q0496, Q0497, Q0498, Q0501, Q0502, Q0503, Q0504, Q0506, S8423, S8425, S8426, S8540, V5030, V5050, V5060, V5100, V5120, V5130, V5140, V5170, V5180, V5210, V5220, V5242, V5243, V5244, V5245, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261 Removed/No PA Required: 20660, 36260, 37242, 37243, 36245, 61796, 61797, 61798*, 61799, 63620*, 63621, 75894, 75896, 77261, 77262, 77263, 77280, 77285, 77290, 77295, 77300, 77301, 77306, 77307, 77316, 77338, 77370, 77371, 77317, 77318, 77372*, 77321, 77331, 77332,77333, 77334*, 77336, 77373*, 77385*, 77387, 77401, 77402, 77407,77412, 77417, 77424, 77425*, 77427, 77431, 77432, 77435, 77469, 77470, 77750, 77776, 77777, 77778, 79445, 96446, S2095 *No PA required for MHSC s DAODAS providers. Retro to 07/01/15 MHPR: Case-by-case evaluation *MHWA/MHMI/ MHTX: PA Required 07/22/15 08/01/15 PT/OT/ST/Habilitative Therapy Removed/No PA Required: 97010, 97012, 97014, MHPR: Non-Covered Benefit 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97110, 97112, 97113, 97116, 97124, 97140, 97530, 97532, 97533, 97535, 97537, 97542, 97760, 97761, 97762, G0281, G0283, G0329, /22/15 08/01/15 Sleep Studies Removed/No PA Required: G0399, G0400, G /22/15 08/01/15 Wound Therapies Removed/No PA Required: 97597, 97598, 97605*, 97606*, 97610, 97602, 97607, 97608, E2402* *MHPR: PA Required Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 5

6 , PA Code Matrix Received Effective Date Date Specialty/Service Change/Update Description Exceptions/Notes 07/22/15 08/01/15 Rehab OP Services Removed/No PA Required: 77293, 93797, 93798, 94669, G0422, G0423, G /22/15 08/01/15 Prosthetics & Orthotics Removed/No PA Required: E0457, E1800, E1801, E1802, E1805, E1806, E1818, E1825, E1840, E1841, L0112, L0113, L0170, L0174, L0180, L0190, L0200, L0220, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0488, L0490, L0491, L0492, L0627, L0631, L0633, L0635, L0636, L0637, L0639, L0641, L0642, L0643, L0649, L0650, L0651, L1200, L1210, L1220, L1230, L1300, L1310, L1650, L1652, L1686, L1690, L1832, L1843, L1845, L1847, L1850, L1910, L1930, L1932, L1951, L1971, L2132, L2134, L2136, L2250, L2280, L2300, L2310, L2320, L2330, L2335, L2340, L2350, L2370, L2380, L2385, L2387, L2390, L2395, L2492, L2500, L2510, L2520, L2525, L2526, L2530, L2540, L2550, L2570, L2580, L2600, L2610, L2620, L2622, L2624, L2627, L2628, L2630, L2640, L2750, L2755, L2768, L3000, L3001*, L3002*, L3003*, L3010*, L3020*, L3030*, L3031*, L3330, L3671, L3674, L3702, L3720, L3730, L3740, L3760, L3763, L3764, L3765, L3766, L3806, L3807, L3808, L3900, L3901, L3904, L3905, L3906, L3913, L3915, L3919, L3921, L3933, L3935, L3960, L3961, L3962, L3967, L3971, L3973, L3975, L3976, L3977, L3978, L4000, L4010, L4020, L4030, L4040, L4045, L4050, L4055, L4060, L4070, L4080, L4090, L4100, L4130, L4205, L4210, L4360, L4396, L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5670, L5671, L5672, L5673, L5676, L5677, L5679, L5680, L5681, L5682, L5683, L5688, L5695, L5700, L5701, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5930, L5940, L5950, L5960, L5961, L5962, L5964, L5968, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L6000, L6010, L6020, L6050, L6055, L6100, L6110, L6120, L6130, L6200, L6250, L6350, L6360, L6370, L6400, L6580, L6582, L6584, L6586, L6588, L6590, L6611, L6620, L6621, L6622, L6623, L6624, L6625, L6628, L6630, L6637, L6638, L6640, L6642, L6645, L6646, L6647, L6648, L6650, L6677, L6680, L6682, L6684, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6703, L6704, L6706, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6805, L6880, L6881, L6882, L6883, L6884, L6885, L6895, L6900, L6905, L6910, L6915, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, *PA Required for NM only. Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 6

7 , PA Code Matrix Received Date Effective Date Specialty/Service Change/Update Description Exceptions/Notes L7180, L7181, L7185, L7186, L7190, L7191, L7360, L7362, L7364, L7366, L7367, L7368, L7400, L7401, L7402, L7403, L7404, L7505, L7900, L8040, L8041, L8042, L8043, L8044, L8045, L8046, L8047, L8400, L8410, L8420, L8430, L8470, L8480, L8500, L8510, L8603,L8604, L8605, L8606, L8614, L8615, L8619, L8627, L8628, L8681, L8689, L8690, L8691, L8693, S1040, V2623, V /22/15 08/01/15 OP Hospital/ASC procedures Removed/No PA Required: 26111, 26113, 26115, 26116, 26117, 26118, 25073, 24079,36818, 36819, 36820, 36823, 36825, 36830, 36835, 36838, 37193, 91010, 91020, 91022, 91030, 91034, 91035, 91037, 91038, 91040, 91122, 91117, 91120, 92611, 92612, 92613, 92970, 92971, 92986, 92987, 92990, 92992, 92993, 92997, 92998, 93224, 93268, 93270, 93292, 93740, 93745, 93770, 93880, 93882, 93886, 93888, 93890, 93892, 93893, 93971, 93922, 93923, 93925, 93926, 93930, 93931, 93961, 93970, 93975, 93976, 93978, 93979, 93980, 93981, 93982, 93990, 94002, 94003, 94004, 94005, 94660, 94774, 94775, 94776, 94777, 95861, 95863, 95864, 95865, 95866, 95908, 95907, 95910, 95887, 95905, 95922, 95924, 95925, 95926, 95927, 93227, 95928, 95929, 95933, 95937, 95938, 95939, 95940, 95941, 95943, 95965, 95966, 95967, 95970, 95971, 95972,95973, 95974, 95975, 95978, 95979, 95980, 95981, 95982, 95991, 95992, 95999, 96000, 96001, 96002, 96003, 96004, 96040, 96361, 96369, 96370, 96371, 96373, 96374, 96375, 96376, 96360, 96523, 97545, 97546, 99143, 99144, 99145, 99148, 99149, /22/15 08/01/15 Cosmetic, Plastic & Removed/ No PA Required: Reconstructive Procedures 07/22/15 08/01/15 Unlisted/Misc./T Codes Removed/ No PA Required: 77299, 77399, /22/15 08/01/15 Neuropsychological & Removed/ No PA Required: 95954, 95955, 95958, Psychological testing 95961, 95962, 07/22/15 08/01/15 Imaging, Advanced & Specialty Removed/ No PA Required: /22/15 08/01/15 Physical Therapy; Occupational Therapy Removed/ No PA Required: 0420, 0421, 0423, 0424, 0422, 0429, 0430, 0432, 0434, 0431, 0433, 0439, /17/15 08/01/15 Sleep Studies Removed/No PA Required: 95800, 95801, 95805, 95806, 95810, 95807, 95811, 95808, /17/15 08/01/15 Temporary Codes (Category 3) Removed T codes Section. Moved codes to Experimental/Investigational: 0019T, 0182T, 0236T, 0295T, 0042T, 0184T, 0237T, 0296T, 0051T, 0188T, 0238T, 0297T, 0052T, 0189T, 0240T, 0298T, 0053T, 0190T, 0241T, 0299T, 0054T, 0191T, 0243T, 0300T, 0055T, 0195T, 0244T, 0301T, 0058T, 0196T, 0249T, 0302T, 0071T, 0198T, 0253T, 0303T, 0072T, 0200T, 0254T, 0304T, 0075T, 0201T, 0255T, 0305T, 0076T, 0202T, 0262T, 0306T, 0085T, 0205T, 0263T, 0307T, 0095T, 0206T, 0264T, 0308T, 0098T, 0207T, 0265T, 0309T, 0099T, 0208T, 0266T, 0310T, 0100T, 0209T, 0267T, 0311T, 0101T, 0210T, 0268T, 0312T, 0102T, 0211T, 0269T, 0313T, 0103T, 0212T, 0270T, 0314T, 0106T, 0213T, 0271T, 0315T, 0107T, 0214T, 0272T, 0316T, 0108T, 0215T, 0273T, 0317T, 0109T, 0216T, 0274T, 0335T, 0110T, 0217T, 0275T, 0336T, 0111T, 0218T, 0278T, 0337T, 0123T, 0219T, 0281T, 0338T, 0126T, 0220T, 0282T, 0339T, 0159T, 0221T, 0283T, 0340T, 0163T, 0222T, 0284T, 0342T, 0164T, 0223T, 0285T, 0347T, 0165T, 0224T, 0286T, 0348T, 0169T, 0225T, 0287T, 0349T, 0171T, 0228T, 0288T, 0350T, 0172T, 0229T, 0289T, 0351T, 0174T, 0230T, 0290T, Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 7 MHPR MHTX (TX Allows only 1 sleep study per year). All other plans require PA.

8 , PA Code Matrix Received Date Effective Date Specialty/Service Change/Update Description Exceptions/Notes 0352T, 0175T, 0231T, 0291T, 0353T, 0178T, 0233T, 0292T, 0354T, 0179T, 0234T, 0293T, 0355T, 0180T, 0235T, 0294T, 0356T, 0357T, 0358T, 0359T, 0360T, 0361T, 0362T, 0363T, 0364T, 0365T, 0366T, 0367T, 0368T, 0369T, 0370T, 0371T, 0372T, 0373T, 0374T, 0392T, 0393T Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 8

9 , PA Code Matrix Behavioral Health, Mental Health, Alcohol & Chemical Dependency Services Inpatient, Residential Treatment, Partial Hospitalization, Day Treatment, Electroconvulsive Therapy (ECT), Applied Behavioral Analysis (ABA) for treatment of Autism Spectrum Disorder (ASD) PLEASE NOTE: Molina of Florida: Contact Psych Care Medicaid: , Medicare/Marketplace: Molina of New Mexico Medicaid: No Auth required when done in an OP setting Molina of Illinois: No Auth required when done in an OP setting Molina of Puerto Rico: Managed by First Health Care (FHC). No Auth required when done in an OP Setting MEDICARE/MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE H0012^ H2019^ T1023^ N/A N/A N/A H0017 H2020 T1025^ H2012 H0031^ T1026^ H2013 H0032*^ T1027^ H2014^ H0046 T1028^ H2015 S5111 T2013^ H2016 S0201 T2040^ 0901 H2017^ S5150^ 0912 H NOTES: *MHSC: No PA required for this code when submitted by DAODAS providers. ^PA required for all plans only when submitted with Autism Dx. [IDC9: , , , , , , , and ICD10: F84.0, F84.2, F84.3, F84.4, F84.5, F84.8, F84.9] Cosmetic, Plastic & Reconstructive Procedures (in ANY setting) MEDICARE/MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE N/A N/A N/A Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 9

10 , PA Code Matrix Durable Medical Equipment (DME) Medicare Hearing Supplemental benefit: Contact AVESIS at PLEASE NOTE: Molina of Florida: codes listed below apply to Region 4 providers only, other MFL regions contact UNIVITA at Molina of Puerto Rico: All DME requires authorization and will be evaluated case-by-case MEDICARE/MEDICAID & MKT PLACE MEDICAID MEDI CARE A7025 E0460 E1002 E1310 E2340 E2608 K0606 K0840 K0880 E0481 S1036 N/A N/A C2624 E0461 E1003 E1399 E2341 E2609 K0800 K0841 K0884 S1034 S1037 E0194 E0462 E1004 E1700 E2342 E2611 K0801 K0842 K0885 S1035 E0255 E0463 E1005 E2201 E2343 E2612 K0802 K0843 K0886 E0256 E0464 E1006 E2202 E2351 E2613 K0806 K0848 K0890 E0260 E0483 E1007 E2203 E2361 E2614 K0807 K0849 K0891 E0261 E0691 E1008 E2204 E2366 E2615 K0808 K0850 K0900 E0265 E0692 E1010 E2227 E2367 E2616 K0813 K0851 Q0479 E0266 E0693 E1014 E2228 E2368 E2617 K0814 K0852 S1040 E0277 E0694 E1020 E2291 E2369 E2620 K0815 K0853 V2530 E0292 E0747 E1029 E2292 E2370 E2621 K0816 K0854 V2531 E0293 E0748 E1030 E2293 E2373 E2622 K0820 K0855 E0294 E0749 E1035 E2294 E2374 E2623 K0821 K0856 E0295 E0760 E1036 E2295 E2375 E2624 K0822 K0857 E0296 E0762 E1161 E2310 E2376 E2625 K0823 K0858 E0297 E0764 E1225 E2311 E2377 E2626 K0824 K0859 E0300 E0782 E1226 E2312 E2378 E2627 K0825 K0860 E0301 E0783 E1227 E2313 E2397 E2628 K0826 K0861 E0302 E0784 E1230 E2321 E2500 E2629 K0827 K0862 E0303 E0785 E1232 E2322 E2502 E2630 K0828 K0863 E0304 E0786 E1233 E2325 E2504 E2631 K0829 K0864 E0328 E0849 E1234 E2326 E2506 K0008 K0830 K0868 E0329 E0855 E1235 E2327 E2508 K0009 K0831 K0869 E0371 E0983 E1236 E2328 E2510 K0010 K0835 K0870 E0372 E0984 E1237 E2329 E2511 K0011 K0836 K0871 E0373 E0986 E1238 E2330 E2605 K0012 K0837 K0877 E0988 E1296 E2606 K0014 K0838 K0878 E1298 E2607 K0108 K0839 K0879 MKT PL Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 10

11 Experimental/Investigational, PA Code Matrix MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE 0019T 0182T 0236T 0295T 0357T 0329T 0332T 0331T 0042T 0184T 0237T 0296T 0358T 0330T 0333T 0051T 0188T 0238T 0297T 0359T 0052T 0189T 0240T 0298T 0360T 0053T 0190T 0241T 0299T 0361T 0054T 0191T 0243T 0300T 0362T 0055T 0195T 0244T 0301T 0363T 0058T 0196T 0249T 0302T 0364T 0071T 0198T 0253T 0303T 0365T 0072T 0200T 0254T 0304T 0366T 0075T 0201T 0255T 0305T 0367T 0076T 0202T 0262T 0306T 0368T 0085T 0205T 0263T 0307T 0369T 0095T 0206T 0264T 0308T 0370T 0098T 0207T 0265T 0309T 0371T 0099T 0208T 0266T 0310T 0372T 0100T 0209T 0267T 0311T 0373T 0101T 0210T 0268T 0312T 0374T 0102T 0211T 0269T 0313T 0392T 0103T 0212T 0270T 0314T 0393T 0106T 0213T 0271T 0315T T 0214T 0272T 0316T T 0215T 0273T 0317T T 0216T 0274T 0335T T 0217T 0275T 0336T T 0218T 0278T 0337T T 0219T 0281T 0338T T 0220T 0282T 0339T J T 0221T 0283T 0340T 0163T 0222T 0284T 0342T 0164T 0223T 0285T 0347T 0165T 0224T 0286T 0348T 0169T 0225T 0287T 0349T 0171T 0228T 0288T 0350T 0172T 0229T 0289T 0351T 0174T 0230T 0290T 0352T 0175T 0231T 0291T 0353T 0178T 0233T 0292T 0354T 0179T 0234T 0293T 0355T 0180T 0235T 0294T 0356T Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 11

12 , PA Code Matrix Genetic Counseling & Testing PLEASE NOTE: Prenatal diagnosis of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by State regulations MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE S3841 S3861 S S3842 S3865 S S3845 S3866 S S3854 S3870 S M M * M M M *Including Oncotype DX) Habilitative Therapy After initial evaluation plus six (6) visits for outpatient and home settings PLEASE NOTE: Molina of Puerto Rico: Not a covered benefit MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE S9128 S9129 S9152 S9128 S S9129 Home Health Care & Home Infusion After initial evaluation plus six (6) visits; PA may be required for medications associated with Home Infusion. PLEASE NOTE: Molina of Florida: codes listed apply to Region 4 providers; other MHFL regions contact UNIVITA at Also see FL Plan exceptions Molina of Puerto Rico: All Home Health visits are a value added services and require MD review MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE G0151 G0154 G0156 G0159 G0162 S X 034X 056X S G0152 G0155 G0157 G0160 G X X G0153 G0158 G0161 G X 043X 060X 032X 044X 062X 033X 055X Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 12

13 , PA Code Matrix Hyperbaric Therapy MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE G Imaging Advanced & Specialty MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE C C C C C C C C C C C C C C C C C C C C C C C C G Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 13

14 , PA Code Matrix In-Patient Admissions Acute Hospital, Skilled Nursing Facilities (SNF), Rehabilitation, Long Term Acute Care (LTAC) Facility PLEASE NOTE: Molina of Puerto Rico: SNF & LTAC are Value Added Services and require MD review MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE All Codes All Codes All Codes All Codes Long Term Services & Support [Not a Medicare covered benefit] PLEASE NOTE: Molina of Puerto Rico Medicaid: Not a covered benefit MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE S5100 S5101 S5102 S5105 S5125 S5126 S9122 T1019 T1020 T1021 Neuropsychological & Psychological Testing PLEASE NOTE: Molina of New Mexico Medicaid: No authorization needed when services done in an OP setting Molina of Puerto Rico: Authorization required for Medical Diagnosis only MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE Non-Par Offices/Providers/Facilities Auth required for Non-Par Office Visits, Procedures, Labs, Diagnostic Studies, In-patient stays, except for: Emergency Department Services Professional fees associated with ER visit and approved Ambulatory Surgery Center (ASC) or inpatient stay Local Health Department (LHD) services Other services based on State requirements Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 14

15 , PA Code Matrix Office Based Procedures PAR Physician/Provider office-based procedures do not require PA, see above for Non-PAR. Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures MEDICARE / MEDICAID & MKT PLACE MEDI- CAID MEDI- CARE MKT PLACE Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 15

16 , PA Code Matrix Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures MEDICARE / MEDICAID & MKT PLACE F F F F F F F F F F F F F F F MEDI- CAID MEDI- CARE MKT PLACE Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 16

17 , PA Code Matrix Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures MEDICARE / MEDICAID & MKT PLACE MEDI- CAID MEDI- CARE MKT PLACE Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 17

18 , PA Code Matrix Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures MEDICARE / MEDICAID & MKT PLACE MEDI- CAID MEDI- CARE MKT PLACE Pain Management Procedures Except trigger point injections [Acupuncture is not a Medicare covered benefit] MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE G * *MHSC does not require PA for this code Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 18

19 Pregnancy and Delivery Notification Only, PA Code Matrix MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE Prosthetics & Orthotics MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE L0480 L1700 L1940 L2037 L6026 L8692 N/A N/A L0482 L1710 L1945 L2038 L7259 L0484 L1720 L1950 L2050 L0486 L1730 L1960 L2060 L0622 L1755 L1970 L2080 L0640 L1834 L1980 L2090 L0700 L1840 L1990 L2106 L0710 L1844 L2000 L2108 L1000 L1846 L2005 L2126 L1005 L1860 L2010 L2128 L1110 L1900 L2020 L2232 L1640 L1904 L2030 L2800 L1680 L1907 L2034 L4631 L1685 L1920 L2036 L0452 Radiation Therapy & Radio Surgery MEDICARE / MEDICAID & MKT PLACE G0339 G6015 G G0340 G6016 MEDICAID MEDICARE MKT PLACE Sleep Studies PLEASE NOTE: Molina of Puerto Rico: Sleep Studies are not a covered benefit MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE 95800* 95806* 95810* N/A N/A N/A 95801* 95807* 95811* 95805* 95808* 95803* *MHTX No PA Required. (TX Allows only 1 sleep study per year) Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 19

20 Speech Therapy After initial evaluation plus six (6) visits for outpatient and home settings PLEASE NOTE:, PA Code Matrix Molina of South Carolina requires auth for all visits after initial evaluation Molina of Puerto Rico: All Speech Therapy visits including evaluations require authorization MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE S9128 S9152 N/A S9128 S Specialty Pharmacy Drugs (Injectable) MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE J0574 J1675 J3110 J7309 J8499 C9136 N/A N/A N/A J0881 J1743 J3240 J7310 J8530 C9442 C9025 J0885 J1744 J3262 J7311 J8562 C9443 C9026 J0890 J1745 J3285 J7312 J8999 C9027 C9132 J0895 J1786 J3315 J7316 J9019 C9444 C9399 J0897 J0575 J3357 J7321 J9042 C9446 C9441 J1290 J0888 J3385 J7323 J9047 Q0515 C9497 J1300 J1322 J3396 J7324 J9202 Q2028 J0129 J1324 J1826 J3487 J7325 J9212 Q2043 J0135 J1325 J1830 J7181 J7326 J9213 Q2050 J0178 J1438 J1930 J7182 J7330 J9214 Q3027 J0180 J1442 J1931 J7200 J7500 J9216 Q3028 J0207 J1446 J2170 J3489 J7327 J9262 S0145 J0215 J1458 J2278 J3490 J7336 J9293 S0148 J0220 J1459 J2315 J3590 J9267 J9302 J1725 J0221 J1460 J2323 J7178 J9301 J9306 J0598 J0256 J1556 J2353 J7180 J7506 J9307 J9010 J0257 J1557 J2354 J7183 J7507 J9310 J9035 J0401 J1559 J2355 J7185 J7508 J9315 J2796 J0480 J1560 J2357 J7186 J7510 J9351 J7336 J0485 J1561 J2426 J7187 J7513 J9354 J2212 J0490 J1562 J2440 J7189 J7515 J9371 S0073 J0585 J1566 J2503 J7190 J7516 J9400 C9445 J0586 J1568 J2505 J7191 J7517 J9600 C9449 J0587 J1569 J2507 J7192 J7525 J9228 C9450 J0588 J1571 J2597 J7193 J7527 Q4074 C9451 J0597 J1572 J2778 J7194 J7639 Q4101 C9452 J0638 J1573 J2793 J7195 J7682 Q4139 C9453 J0717 J1595 J2820 J7196 J7686 Q4145 C9454 J0740 J1599 J2940 J7197 J9217 Q4149 C9455 J0775 J1602 J2941 J7198 J9218 Q5101 J0800 J1645 J3030 J7199 J9219 Q9975 J0850 J1650 J3060 J7502 J9225 Q9977 J0572 J1652 J7201 J7504 J9226 Q9978 J0573 J1950 J3488 J7505 J9245 MKT PLACE Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 20

21 Transplant Services (Including Solid Organ and Bone Marrow) Corneal Transplants do not require PA PLEASE NOTE: Molina of Puerto Rico: Not a covered benefit, PA Code Matrix MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE S2065 N/A S S2053 S2140 S2053 S S2054 S2142 S2054 S S2055 S2150 S2055 S S2060 S2152 S2060 S S2061 S Transportation Services (Non-Emergent) PA required for Non-Emergent Ambulance (air or ground). Emergent transport does not require PA MEDICARE / MEDICAID & MKT PLACE MEDICAID MEDICARE MKT PLACE A0426 A0428 A0430 A0431 S9960 S9961 N/A S9960 S9961 A0999 Unlisted/Miscellaneous Codes Unlisted/Miscellaneous Codes Molina requires medical necessity documentation and rationale be submitted with the PA request for these codes: MEDICAID MEDICARE MKT PLACE MEDICARE / MEDICAID & MKT PLACE D0502 D6199 D0502 D D0999 D6999 D0999 D D2999 D7999 D2999 D D3999 D8999 D3999 D A4649 D4999 D9630 D4999 D * A4913 D5899 D9999 D5899 D A9999 D5999 T5999 D5999 T B E E E E G J7599 Q MHI PA Code Matrix (Eff Aug 2015 v2).docx Page 21